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Disordered eating and food restrictions in children with pandas/pans

JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY
Volume xx, Number x, 20xxª Mary Ann Liebert, Inc.Pp. 1–9DOI: 10.1089/cap.2014.0063
Disordered Eating and Food Restrictions
in Children with PANDAS/PANS
Megan D. Toufexis, DO,1 Rebecca Hommer, MD,2 Diana M. Gerardi, MA,1 Paul Grant, MD,2
Leah Rothschild, BA,2 Precilla D'Souza, NP,2 Kyle Williams, MD,3,4
James Leckman, MD, PhD,5 Susan E. Swedo, MD,2 and Tanya K. Murphy, MD, MS1,6
Objective: Sudden onset clinically significant eating restrictions are a defining feature of the clinical presentation of some ofthe cases of pediatric acute-onset neuropsychiatric syndrome (PANS). Restrictions in food intake are typically fueled bycontamination fears; fears of choking, vomiting, or swallowing; and/or sensory issues, such as texture, taste, or olfactoryconcerns. However, body image distortions may also be present. We investigate the clinical presentation of PANS disorderedeating and compare it with that of other eating disorders.Methods: We describe 29 patients who met diagnostic criteria for PANS. Most also exhibited evidence that the symptomsmight be sequelae of infections with Group A streptococcal bacteria (the pediatric autoimmune neuropsychiatric disorderassociated with streptococcal infections [PANDAS] subgroup of PANS).Results: The clinical presentations are remarkable for a male predominance (2:1 M:F), young age of the affected children(mean = 9 years; range 5–12 years), acuity of symptom onset, and comorbid neuropsychiatric symptoms.Conclusions: The food refusal associated with PANS is compared with symptoms listed for the new Diagnostic andStatistical Manual of Mental Disorders, 5th ed. (DSM-V) diagnosis of avoidant/restrictive food intake disorder (ARFID).Treatment implications are discussed, as well as directions for further research.
growing body of literature documenting that viral and bacterialinfections can precipitate acute-onset food restriction (Patton et al.
In addition to the sudden overnight onset of classic 1986; Park et al. 1995; Sokol and Gray 1997; Simon 1998; Sokol
obsessive-compulsive symptoms, the sudden onset of reduced
2000, Watkins et al. 2001; Storch et al. 2004; Calkin and Carandang
and restricted food intake is one of the defining diagnostic symptoms
2007). Systemic diseases, including autoimmune disorders such as
of pediatric acute-onset neuropsychiatric syndrome (PANS) (Swedo
systemic lupus erythematosus (Toulany et al. 2014), have also been
et al. 2012). Multiple etiologies for PANS have been hypothesized,
reported to cause food restrictions via immune dysregulation. An-
ranging from genetic and immunologic disorders to postinfectious
orexia nervosa (AN) has also been postulated to result when dis-
sequelae. When the symptoms are preceded by a group A strepto-
ease-related loss of appetite produces excessive weight loss (Dally
coccal (GAS) infection, the condition is referred to as ‘‘pediatric
1969; Beumont et al. 1978) and subsequent development of body
autoimmune neuropsychiatric disorder associated with streptococcal
image distortions.
infections'' (PANDAS) (Swedo et al. 1998). In 1997, Sokol and
In youth with PANDAS, food restriction has been reported to
Gray described the first cases of ‘‘PANDAS anorexia'' (PANDAS-
occur in the context of obsessional fears about contamination, as
AN) in their eating disorders unit at the Menninger clinic (Sokol
well as in the context of the sudden onset of fears of swallowing,
and Gray 1997). Notably, the PANDAS-AN patients described
choking, or vomiting that are often associated with sensory phe-
were prepubescent, feared weight gain as a result of body dys-
nomena (e.g., the perceived texture or appearance of the food). In
morphic issues, and exhibited symptoms temporally related to a
rare instances, these fears lead to the child's refusal to ingest
GAS infection. Additional reports document positive GAS cultures
anything orally including any liquids. Contamination fears may
among youth with abrupt onset of choking fears and refusal to
lead to dietary restriction of all or selected food items (Bernstein
swallow (Henry et al. 1999). These observations contribute to a
et al. 2010). For example, a child with PANDAS was reported to
1Division of Pediatric Neuropsychiatry, Rothman Center, Department of Pediatrics, University of South Florida, St. Petersburg, Florida.2Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda, Maryland.3Pediatric Neuropsychiatry and Immunology Clinic, Massachusetts General Hospital, Boston, Massachusetts.4Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.5Child Study Center, Yale University School of Medicine, New Haven, Connecticut.6Department of Psychiatry, University of South Florida, Tampa, Florida.This research was supported (in part) by the Intramural Research Program of the NIMH, including protocol 11-M-0058 (NCT01281969).
TOUFEXIS ET AL.
have a fear of choking and contamination that led to complete
children had tics, with an average YGTSS = 16.6 ( – 7.9 SD) (see
cessation of food consumption and loss of 10% of the subject's
Table 1). Two thirds (n = 19) of the children (66%) reported that
body weight (Storch et al. 2004). Another report detailed the abrupt
their food restrictions were secondary to contamination fears (see
onset of obsessions about choking, accompanied by refusal to
Table 2). Of those with contamination fears, 12 had fears involving
swallow, in association with a positive GAS culture (Henry et al.
germs, three had fears involving poison, and one each had fears of
1999). Restricted eating also has been reported to occur secondary
allergens, bleach, illicit drugs, or ‘‘the essence and personality of
to new onset of body image distortions of being ‘‘too fat'' or not
other people.'' Others expressed fears of vomiting (28%, n = 8) or
having a ‘‘six-pack'' (Swedo et al. 2012). To date, little has been
choking (21%, n = 6). In addition to food restriction, five patients
published on food restrictions in PANS. We report experience with
(17.2%) refused to swallow their own saliva, and another five re-
29 patients who met criteria for PANS and who also exhibited
fused all food for several days or longer. Three children (10%)
acute-onset food restriction.
expressed concerns about weight or body shape. Mean change inweight (in pounds) was - 4.21 ( – 5.85 SD) and mean percent body
weight change was - 4.89% (1.91 kg – - 2.66 SD). In the USFsample, 12 out of 13 cases, and in the NIMH sample 14 out of 16
The patients described in this series were participants in clinical
cases, had generalized OCD in addition to food restriction. Mean
trials at the National Institute of Mental Health (NIMH) or at the
illness duration was 2.68 months ( – 1.68 SD). For PANS neuro-
Rothman Center of Neuropsychiatry at the University of South
psychiatric symptoms, see Table 3.
Florida (USF). All subjects met criteria for PANDAS or PANS and
Eighteen children (62%) were confirmed to have had a positive
reported new, abrupt onset of eating restrictions or food avoidance.
rapid GAS test or culture at or near the time of PANS onset
Children participating in the NIMH trial (n = 16) were among a
(See Table 1). Six youth had been exposed to GAS. Mycoplasma
larger cohort enrolled in a study of intravenous immunoglobulin
pneumonia (MP) exposure or infection was evident in 4 of 12
(IVIG) for the treatment of PANDAS (NCT01281969). This study
children examined, 3 of whom (all male) had positive MP immu-
was approved by the National Institutes of Health (NIH) Central
noglobulin (Ig) G and negative MP IgM, and 1 of whom (female)
Nervous System (CNS) institutional review board (IRB); parents
had positive MP IgG and IgM. A few children had more than one
provided informed consent and children provided assent for study
reported infectious trigger.
participation. Children included from USF (n = 13) were fromthree studies, with most from a larger cohort of participants in astudy investigating azithromycin as a PANS treatment (n = 10;
NCT01617083, 6119-128500). These studies were approved by the
Patient 8 was an 8-year-old male who presented to
USF-affiliated IRB; parents provided informed consent and chil-
USF 1 month following the sudden onset of severe acute-onset
dren provided assent for study participation. All of the patients met
contamination fears, food refusal, and tics. Past medical history was
full criteria for PANS; some also had evidence of preceding GAS
significant for a viral infection (gastrointestinal [GI] symptoms)
infections and, therefore, met criteria for PANDAS. Pertinent
immediately preceding the PANS symptoms, and a lifetime history
subject data are summarized in Table 1.
of frequent GAS infections leading to adenotonsillectomy. Pre-morbid psychiatric history was notable for attention-deficit/ hy-
peractivity disorder (ADHD) and minor separation anxiety disorder
Symptom severity was measured using the Children's Yale-
(SAD). Physical examination was only remarkable for moderate
Brown Obsessive Compulsive Scale (CY-BOCS) (Scahill et al.
livedo reticularis. The patient started having fears of dying sud-
1997) and Yale Global Tic Severity Scale (YGTSS) (Leckman
denly while he and his family were at a restaurant. He thought he
et al. 1989). All assessments were conducted or reviewed by trained
was having an allergic reaction, and despite efforts to assuage his
clinicians with experience in pediatric obsessive-compulsive dis-
anxiety, he began having a panic attack. Although he had no history
order (OCD) and tic disorders. Comorbidity symptoms were col-
of food allergies, he then developed contamination fears related to
lected at both sites using PANS/PANDAS checklists as well as
allergens in food, and he refused to eat most solid food. His mother
symptoms deemed present in the clinical evaluation.
reported that when she attempted to give him dry toast, he refused
Laboratory tests for streptococcal infection included anti-DNase
to eat it and began to dry heave. In addition to allergens, he ex-
B and antistreptolysin O (ASO) titers. Because of differences in
pressed concern that ‘‘other people's medications'' were in his
laboratory standardization, thresholds of elevation differed be-
food. At evaluation 1 month post-onset, the parents reported that
tween sites. Thresholds used to designate groups into elevated or
the child had lost 2 lb (3% of his body weight). All laboratory
unelevated categories at each site were as follows: ASO > 160 IU/mL
values were within normal limits, including streptococcal and
for ages 0–6 and > 200 IU/mL for ages 7–17 (USF); ages 5–17
mycoplasma titers. Out of a desperate desire to get him to eat, his
years > 640 IU/mL (NIMH); anti-DNase B > 60 U/mL for ages 0–6
mother began giving him fake allergy pills (i.e., Sweet Tarts), so
and > 170 U/mL for ages 7–17 (USF); > 375 U/mL (NIMH). As-
that he would eat more. However, this measure soon failed, and the
says were performed by the USF clinical research laboratory, or
boy's contamination fears generalized to the point where his intake
for NIMH subjects, Mayo Medical Laboratories in Rochester,
was limited to clear liquids. He was started on azithryomycin
treatment and, within 1 month, his worries about allergens andmedication poisoning were near remission, and he was eating anddrinking normally.
Twenty-nine children are the subjects of this report, including 20
Patient 12 was a 10-year-old male with a past
males (69%) and nine females (31%), with mean age of 9 years
history of ADHD, who presented at NIH with sudden-onset severe
(range 5–12 years). All children reported obsessive-compulsive
OCD and a specific fear that his hands and lips were contaminated
symptoms, with an average CY-BOCS = 30.1 ( – 5.2 SD). Eighteen
with bleach cleaner. He had tested positive for GAS and had been
DISORDERED EATING IN PANDAS/PANS
Table 1. Patient Demographics, Premorbid History, Baseline Scores, and Laboratory Results
History of infection
Exposure to viral
Frequent staphylococcal
Exposure to virus
(rapid antigendetection negative)
Infantile febrile seizures
Speech delayTics (mild)
Frequent otitis mediaPE tubes
Frequent otitis mediaPE tubes
Borderline adrenal
suppression(secondary to inhaledcorticosteroids)
Frequent otitis media
(rapid antigendetection negative)
(rapid antigendetection negative)
(rapid antigendetection negative)
TOUFEXIS ET AL.
Table 1. (Continued)
History of infection
Confirmed Influenza
Frequent otitis mediaT&ATics with EBV
Frequent otitis media
CYBOCS, Children's Yale-Brown Obsessive Compulsive Scale; YGTSS, Yale Global Tic Severity Scale; ASO, antistreptolysin O; SAD, separation
anxiety disorder; T&A, tonsil and adenoid surgery; GAD, generalized anxiety disorder; URI, upper respiratory infection; ADHD, attention-deficit/hyperactivity disorder; PE, pressure equalizer, GERD, gastroesophageal reflux disease; EBV, Epstein–Barr virus.
exposed to siblings who tested positive for GAS prior to his sudden
constantly apologized and expressed guilt about supposed trans-
onset of symptoms. The GAS infection was treated with a 5 day
gressions and would hit herself on the head or engage in other self-
course of azithromycin. After the children's GAS infections, their
mother cleaned the house with bleach, and shortly afterwards, the
At the time of presentation to NIH, the child's overscrupulosity
patient developed an obsession that any food he touched would
had escalated to the point that she felt she ‘‘did not deserve to eat''
become contaminated with bleach, harming or killing him. Even
or do other pleasurable things such as watch television. She espe-
when his mother removed all bleach from the house, the child no
cially refused to eat foods that she considered ‘‘treats,'' such as
longer allowed her to prepare his food, as he believed she was
cookies and other foods with sugar. She insisted that her mother not
‘‘contaminated.'' When his father performed yard work using fer-
pack treats in her lunch, and if her mother packed a treat anyway,
tilizer, the child believed that his father was also now ‘‘contami-
the child refused to eat it and would bring it home or give it away to
nated.'' The child began to spit out or throw away any food that
friends. During the structured interview, she admitted that she was
touched his hands or lips. He constantly sought reassurance from
somewhat preoccupied with her appearance and thought that an
his parents by asking, ‘‘Is this bleach? Will bleach kill me?'' In
unrealistically thin doll represented an ideal to which to aspire.
addition, he engaged in excessive showering, hand washing, and
This patient was prescribed a 2 week course of amoxicillin by an
tooth brushing behaviors. He would only eat food that was cut into
outside physician * 3 weeks after symptom onset. Two weeks later
long ‘‘french fry'' shapes so that he could pass the food into his
(and 4 weeks prior to study enrollment), amoxicillin-clavulanic
mouth without it touching his lips, and eventually he refused to eat
acid was started by an outside physician for GAS prophylaxis; this
completely. This contamination fear generalized to the point that he
medication was continued throughout the duration of NIH study
would not swallow even his own saliva, and would instead hold his
participation as well. At NIH, this patient was treated with IVIG per
saliva in his mouth at school until he could go to the bathroom and
protocol at baseline and 6 weeks, and made a full recovery with
spit it out. Because of intense contamination fears, the child had
only slight residual generalized anxiety. Her parents reported that
restricted his caloric intake to between 800 and 1000 calories daily,
she was still a selective eater, but that her food intake was adequate.
without expressed desire to lose weight or dissatisfaction with hisbody. He also reported feeling hungry and was distressed by his
Patient 24 was a 7-year-old girl with unremark-
inability to eat, even expressing suicidal ideation when frustrated.
able premorbid medical or psychiatric history who presented to
Upon entering the NIH study, this child was prescribed penicillin
NIH with complaints of acute-onset OCD that began 9 months prior
as prophylaxis against future GAS infections, and 2 g/kg of IVIG
to evaluation. At that time, she abruptly displayed a compulsive
over a course of 2 days. Six weeks later, the patient and his parents
need to carry a plastic bucket at all times secondary to fears of
reported a 90–95% improvement in his symptoms.
vomiting. She expressed fears of choking, and subsequently refusedto eat for 3 consecutive days. She developed fear of contaminants
Patient 13 was an 8-year-old female who had a
and fear that harm might come to her. She also became unchar-
sudden onset of OCD symptoms including excessive confessing,
acteristically irritable and aggressive, and she displayed severe
concern with right and wrong, and contamination fears. She had
separation anxiety, behavioral regression, inattentiveness, hyper-
been exposed to GAS at school, and she and her fraternal triplet
activity, and insomnia. A rapid GAS test performed at that time was
sisters had flu-like symptoms, but she cultured negative for GAS
negative, but she was prescribed cephalexin. The cephalexin had
pharyngitis. At her baseline visit at NIH, her ASO was 403 (normal
no discernible therapeutic effect; therefore, 5 days later the child's
for age), and anti-DNAse B was elevated at 397. Historically the
pediatrician discontinued cephalexin and prescribed a course of
‘‘healthiest'' of her siblings, the patient experienced a drastic
amoxicillin. Within 36 hours of starting amoxicillin, the child was
change in personality, with extreme perfectionism and concern
described as ‘‘90% back to normal'' according to her parents.
with morals. She constantly confessed to doing something ‘‘wrong''
Amoxicillin was continued for 6 weeks, then stopped for 5 days, but
or ‘‘bad'' on purpose, when in fact she had done nothing. She
was resumed because of worsening behavior and anxiety, and then
DISORDERED EATING IN PANDAS/PANS
Table 2. Food-Related Symptoms and Behaviors
DWeight in kilograms
Food-related fears
Food-related behaviors
(% body weight change)
Contamination fears: Germs;
Restrictive eating
Refusal of solid food;
refusal to swallowsaliva
Contamination fears: Germs;
Refusal to eat unless
father is present
Fear of choking or vomiting
Restrictive eating
Contamination fears: Poison
Restrictive eating
Disgusted by smell and taste of
Restrictive eating
Contamination fears: Illicit
Restrictive eating
Contamination fears: Allergens
Restrictive eating
Contamination fears: Germs
Refusal to consume food
that has been in hishome
Contamination fears: Germs
Refused to eat or drink for
3 days; refusal to eat ordrink unless preparingit herself
Contamination fears:
Restrictive eating; refusal
‘‘Essence'' of others in food
to swallow saliva
Contamination fears: Bleach
Would not allow food to
Yes (value unavailable)
touch his lips; eventualrefusal of solid food;refusal to swallowsaliva
Feeling she didn't deserve to
Restrictive eating
Yes (value unavailable)
eat or do pleasurable things,body image concerns
Contamination fears: Poison
Restrictive eating; refusal
Yes (value unavailable)
to swallow saliva
Contamination fears: Germs
Restrictive eating
Contamination fears: Poison
Refusal to eat for days
Contamination fears: Germs
Restrictive eating
One episode of fear of choking
Decrease in appetite
Contamination fears: Germs
Restrictive eating and
Contamination fears: Germs;
Restrictive eating
Restrictive eating
Yes (value unavailable)
Would not disclose; concerns
Restrictive eating
Yes (value unavailable)
about being overweight
Contamination fears: Germs;
Restrictive eating
Contamination fears: Germs;
Refusal to eat for 3 days
fear of vomiting; fear ofchoking
Refusal to eat for days
Restrictive eating
Fear of choking; Concerns of
Refusal to eat; refusal to
Contamination: Germs
Restrictive eating;
Contamination: Germs;
Restrictive eating
Concerns of beingoverweight
aIndicates child was hospitalized secondary to dehydration.
TOUFEXIS ET AL.
Table 3. Acute-Onset Neuropsychiatric Symptoms
Inattention and/or hyperactivity
Separation anxiety
Behavioral regression
Oppositional or aggressive behaviors
Sensory sensitivity
M, male; F, female; NIMH, National Institute of Mental Health; USF, University of South Florida.
continued for the next 5 months. Following exposure to a relative
body weight, motivated behavior, and mood (Fetissov et al. 2005).
with a documented GAS infection, her symptoms suddenly re-
Furthermore, animal models of antibodies to a-melanocyte stimu-
turned and again included restricted eating secondary to contami-
lating hormones have been found to correlate with feeding behavior
nation fears and obsessions about choking. Rapid GAS testing was
(Coquerel et al. 2012). OCD and anorexia are highly comorbid
negative, and a culture was not obtained. Amoxicillin was contin-
disorders, and structural and metabolic changes in the putamen and
ued during this time, and a brief course of azithromycin was added
caudate have been found in both groups (Rubenstein et al. 1992;
by the child's pediatrician. Amoxicillin was continued during NIH
Harrison et al. 2009; Radua et al. 2010; Kaye et al. 2011; Rothe-
study enrollment, and in conjunction with a blinded infusion of
mund et al. 2011; Friederich et al. 2012). In addition, antiputamen
sham IVIG/placebo, produced a similar reduction in symptom se-
antibodies have been discovered in children with OCD behaviors
verity over the course of 8 weeks.
(Kirvan et al. 2006) and in adolescents with anorexia; serum pos-itivity was found in 6 out of 22 subjects with AN, five of whom hadcomorbid OCD (Harel et al. 2001), suggesting there may be a role
of autoantibodies and immune factors in AN.
The children in this case series displayed acute-onset food re-
Avoidant and restrictive food intake disorder (ARFID) is a new
striction, and concomitant obsessions about contamination, poi-
diagnosis in Diagnostic and Statistical Manual of Mental Dis-
soning, vomiting, or choking. In some instances, disordered eating
orders, 5th ed. (DSM-V) (American Psychiatric Association 2013).
appeared secondary to sensory issues or body image distortions. In
Like other DSM-V disorders, the diagnostic criteria for ARFID
addition to restricted food intake, the children also reported com-
describe a specific clinical presentation, without regard for eti-
pulsive ways of preparing food (e.g., cutting, smelling, arranging,
ology, response to treatment, comorbid symptoms, or even acuity
and ‘‘decontaminating'' food), restricting (e.g., avoiding foods
of onset. The PANS cases described in this series met ARFID
bases on texture, color, smell), or refusing food. Two thirds of the
criteria, as there was a clear eating or feeding disturbance that led to
children had obsessive fears about contaminated food or beverages,
inadequate food intake, accompanied by weight loss in some pa-
and five refused to swallow their saliva because of contamination
tients, and significant psychosocial dysfunction in all patients.
Nearly all of the children in our series had a paralyzing fear of some
Eighteen of the 29 cases (62%) had documented GAS infections
adverse consequence of eating normally, as many felt food was
at or shortly prior to the onset of behavioral symptoms; the re-
poisoned or contaminated, or they had a fear they would vomit or
maining 11 children had evidence of GAS exposure (n = 6) or had
choke. Only three children expressed concerns about body image or
another infection (n = 5). Evidence of recent exposure to MP was
‘‘getting fat,'' but these obsessions developed later in the course of
demonstrated in one patient with a positive MP IgM (MP has been
their symptoms. Because the children were so young, weight loss
implicated in the development of neurologic sequelae [Yis
that would be trivial in an adult (e.g., 1–3 kg) may have been
2008]). Notably, MP has been considered in the pathogenesis of tic
physiologically significant, and the children were at higher risk of
disorders (Mu¨ller et al. 2000, 2004) and is a proposed trigger for
dehydration and electrolyte disturbances. One child was hospital-
PANS (Swedo et al. 2012). Secondary symptoms such as enuresis,
ized secondary to dramatic weight loss, and another required in-
sleep disturbance, anxiety, and mood lability, as well as adventi-
tious movements, are commonly associated with the onset of PANS
As is shown in Table 4, ARFID would seem to capture the
(Bernstein et al. 2010) and were frequently present in these cases
eating disturbances described previously more accurately than
(see Table 3).
AN or another specified feeding or eating disorder. ARFID can
Molecular mimicry is one theory proposed in the etiology of
be diagnosed with other psychiatric diagnoses such as OCD or
PANDAS (Kirvan et al. 2006) and also has been postulated as a
pseudodysphagia if the food restriction or avoidance is severe
mediating factor in the development of restrictive eating disorders
enough to be of clinical focus, or is an extreme characteristic of
(Fetissov et al. 2005), as it is hypothesized that antibodies will cross
the comorbid disorder. In addition, psychiatric conditions, in-
the blood–brain barrier and provoke new onset psychiatric and
cluding food restriction secondary to reactive attachment disor-
neurological symptoms. Research has suggested that eating disor-
der, autism spectrum disorder, trauma associated with choking,
ders may be associated with autoantibodies against a-melanocyte
and specific phobia must be considered, as symptoms of ARFID
stimulating hormone, which is involved in appetite regulation,
can be attributed to these primary diagnoses alone (Kreipe and
DISORDERED EATING IN PANDAS/PANS
Table 4. Comparison of AN, PANDAS ‘‘Anorexia,'' ARFID, and PANS Disordered Eating
PANDAS ‘‘anorexia''
PANS disordered eating
Insidious and usually
Acute and prepubertalc,d,e
Acute and prepubertal
Acute and prepubertal
(most common)f.g.h
Females > > Malesi
Females > Malesc,d,j
Females < Males
Genetic predisposition,
Infection, genetic
temperamental, genetic
imbalance, cultural
and physiologicalf,g,h
Fears of being ‘‘fat,'' fear
Contamination, sensory,
Sensory, lack of interest in
Contamination, sensory,
of weight gain; body
irrational thinking (e.g.,
food; conditioned
irrational thinking
image distortionsa
food seems inedible,
negative response to
(e.g., food seems
inedible, mechanical
Slow, relapse common,
Relatively rapid with
Slow, need to address co-
Relatively rapid with
high mortality ratem
morbidities f,g,h
weight restoration
aKaye 2008; bKlein and Walsh 2003; cSokol 2000; dSokol and Gray 1997; eCalkin and Carandang 2007; fFisher et al. 2014; gKreipe and Palomaki 2012;
hNorris et al. 2014; iAmerican Psychiatric Association 2000; jSokol et al. 2002; kAmerican Psychiatric Association 2013; lStrober 1995; mHalmi et al. 2005.
AN, anorexia nervosa; PANDAS, pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections; ARFID, avoidant/
restrictive food intake disorder; PANS, pediatric acute-onset neuropsychiatric syndrome.
Palomaki 2012). In addition, food neophobia, the avoidance of
Clinical Significance
trying new foods, was not found with our cases, as prior to the
The cases described in this series demonstrate clinically im-
onset of illness our patients consumed typical diets with a variety
portant differences between the disordered eating of PANS and that
of foods (Dovey et al. 2008). As with all psychiatric diagnoses, a
of ARFID or AN. Acuity of onset, male prevalence, and young age
medical condition must be ruled out as the primary cause of
at presentation are the most striking differences, and serve to dis-
the symptoms. Comorbid medical conditions with ARFID and
tinguish the PANS patients from others with eating disorders. In the
eating disorder-like presentations would include gastroparesis,
PANS group, environmental factors, particularly GAS infections,
low oral muscle tone or coordination, dysphagia, achalasia,
can lead to a cascade of immunological, psychological, and phys-
esophagitis, and irritable bowel syndrome. Other potential cau-
ical symptoms that result in abrupt restriction and/or aversion to
ses of presenting symptoms include food allergies and occult
food. Early appropriate diagnosis and treatment of PANS is es-
sential, as prompt treatment with antibiotics or immunomodulatorytherapies can produce dramatic symptom improvements. Further
research is required to determine the best treatment practices fordisordered eating in the PANDAS/PANS cohort.
Eating disorders in children are on the rise, and the burden of
these disorders on the healthcare system is high. Between 1999
and 2006, there was an 119% increase in eating disorder-relatedhospitalizations for children < 12 years of age, per an analysis
Megan D. Toufexis, Rebecca Hommer, Diana M. Gerardi, Paul
performed by the Agency for Healthcare Research and Quality
Grant, Leah Rothschild, Precilla d'Souza, Kyle Williams, and
(Rosen 2010). In particular, the steep rise in males with eating
Susan E. Swedo have no financial relationships to disclose. James
disorders is of concern (Carlat et al. 1997; Rosen 2003; Domine´
Leckman has received support from the NIH (salary and research
et al. 2009). We hypothesize that the rise in eating disorders in
funding), Tourette Syndrome Association (research funding), Gri-
young children, especially in males, as suggested by our cases,
fols, LLC (research funding), and Klingenstein Third Generation
may be linked to a PANS presentation that could be missed by
Foundation (medical student fellowship program). He receives
clinicians. It is noteworthy that there exists a preponderance of
book royalties from John Wiley and Sons, McGraw Hill, and Ox-
males with pediatric OCD (Geller and March 2012) as well as
ford University Press. Tanya Murphy has received research support
PANS (Swedo et al. 2012); the male preponderance seen in our
from All Children's Hospital Research Foundation, AstraZeneca
sample may simply reflect what has been described for pediatric
Neuroscience iMED, Centers for Disease Control, International
OCD. It is our hope that a PANS diagnosis will be considered in
OCD Foundation (IOCDF), NIH, Ortho McNeil Scientific Affairs,
children who develop acute-onset food avoidance or restriction.
Otsuka, Pfizer Pharmaceuticals, Roche Pharmaceuticals, Shire,
The management and outcome of children with a PANS pre-
Sunovion Pharmaceuticals Inc., Tourette Syndrome Association,
sentation differ from those for AN and ARFID, as treatment
and Transcept Pharmaceuticals, Inc. Dr. Murphy is on the Medical
with antibiotics or immunomodulatory therapies is often cura-
Advisory Board for Tourette Syndrome Association and on
tive (Perlmutter et al. 1999; Murphy and Pichichero 2002;
the Scientific Advisory Board for IOCDF and for the PANDAS
Snider et al. 2005; Murphy et al. in press), as in the cases de-
Network. She receives a textbook honorarium from Lawrence
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National Energy Corporation of Trinidad and Tobago Limited BUSINESS OPPORTUNITIES FROM MELAMINE BASED INDUSTRIES UPDATE ON DOWNSTREAM PROJECTS IN DEVELOPMENT Vernon Paltoo Manager, Energy Industry Development ECTT Energy Luncheon November 2011 Outline of Presentation • Overview • Melamine in Manufacturing